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We’ve been around since 2006, and have gained a good reputation for the way MAC communicates safety messages to seafarers and those directly concerned in their management, through its daily posts and frequent audio podcasts – of which there are more than 40 and more will be made available this coming year. It is available free of charge to readers, who are encouraged to share the information. Its language is designed to be lively, engaging, clear and accessible – so we don’t “sound like Head Office”. And it’s sometimes bumptious, because we want seafarers to feel, correctly, that we’re on on their side.

It has become respected by seafarers and maritime safety personnels and is regarded as a credible source of safety-related information. Its founder and administrator, Bob Couttie, is an ambassador for the joint Confidential Hazardous Incident Reporting Programme/Nautical Institute Mariners’ Alerting and Reporting Scheme joint initiative.

Is there anything remotely ambiguous about the signage on this hatch-cover? Why did three seafarers ignore them? Unfortunately the report from the Federal Bureau of Maritime Casualty Investigation on three confined space deaths aboard the German-flagged general cargo ship Suntis does not tell us. Key questions remain unanswered but the circumstances are all too familiar.

Says the report "MV Suntis left the port of Riga in Latvia on 19 May 2014 and reached the port of Goole in the United Kingdom on the evening of Saturday 24 May 2014. The crew was composed of a 67-year-old German master, a 60-year-old German chief officer, and three Philippine seamen (38, 33 and 30 years old). The ship was laden with timber.

"The discharge operation began with the unloading of deck cargo by a shore-based crane and stevedores at about 0545 on Monday 26 May. Two OS were assigned to remove the tarpaulins that were attached to protect the deck cargo on board. One crew member (possibly both) climbed into the forward tween deck hatch during the discharge operation. The chief officer and a third seaman (AB 3 ) noted the absence of the two other crew members and proceeded to look for them. Since the two of them were not found in the aft superstructure, the AB and the chief officer proceeded forward (the AB via the wood loaded main cargo hatch cover and the chief officer on the starboard weather deck). On arriving at the end of the hatch, the AB saw the chief officer call and then climb into the forward hatch to the tween deck. When the AB arrived at and looked into the hatch, he saw the chief officer collapse.

"The AB immediately climbed into another hatch to forecastle's access hatch and switched on the cargo hold's ventilation fan from there. After that, he ran back to the superstructure and alerted the master at about 0645. At the same time, the stevedores were informed that something was reportedly not right on board the Suntis. The AB collected his EEBD, which was stored in the cabin, and a breathing apparatus (BA) set from the aft store. In the confusion, he forgot the full- face mask, however. On arrival back at the forecastle, lifting slings were passed around the three collapsed crew members with the assistance of the two stevedores and they were pulled on to the deck. This involved the two stevedores, one with and one without an EEBD, and the AB with the BA set climbing down the ladder alternately.

"Although the BA also worked to some degree without wearing a mask, the AB and the two stevedores suffered severe breathing difficulties. None of the three crew members who climbed into the hatch survived despite immediate attempts at resuscitation."

Once each victim reached the bottom of the ladder from the hatch they were breathing an atmosphere of about 6 per cent oxygen. Any oxygen concentration below 20 per cent should be regarded as potentially hazardous. At 6 per cent the result is unconsciousness and often death.

Baldly, the casualties died because they broke the rules. The situation is a familiar one – an initial victim enters a dangerous space and collapses. A second person attempts a rescue and also succumbs, followed by another. Two-thirds of confined space casualties are people who have attempted a rescue.

If you don't do it right it's your friends who will die trying to save you.

The BSU describes the rescue attempts as 'reckless' and it's hard to disagree. Inability to use the BA equipment properly and the inappropriate use of an EEBD – a piece of kit that should never be used to enter a dangerous space – suggest strongly that the crew had either not been drilled in confined space rescue or tht any such drills were ineffective. The BSU seems not to have determined what training had been done.

Suntis's SMS looked good on paper: Any compartment or tank that is isolated from the outside air for an extended period is, without exception, defined as an enclosed space and may be entered only with the approval of a ship's officer. The ship's officer must work through and complete a checklist ('Entering a confined space') prior to approving entry to any such compartment. That requires measurement of the ambient air and only then will the master or ship's officer responsible approve entry into the compartment". Yet it seems unlikely that this incident was the first time anyone one the vessel had entered a confined space without following the rules and very likely that it was perceived a mere paper exercise that was unnecessary in the 'real world of seafarers'.

BSU does not address whether a supposed "safe manning" of 5, including the master, is appropriate.

The Confidential Hazardous Incident Programme, CHIRP, raises a number of concerns regarding the official report "For example there is no reference as to training and experience of the crew in the carriage of timber cargoes. Similarly, there is no reference to the hours worked in the previous 24 hours and days in the preceding seven days. Given there is a total crew of 5 including the Master on a two watch system and trading in North European waters, it is difficult to accept there will be an effective SMS in place".

From September to November this year the Paris and Tokyo Memorandums of Understanding on Port State Control will be conducting Concentrated Inspections Campaigns on on crew familiarisation for confined space entry. One suspects that the results will confirm what is already known: Too little is being done to reduce these unacceptable and unnecessary fatalities.

The Confidential Hazardous Incident Programme, CHIRP, raises a number of concerns regarding the official report "For example there is no reference as to training and experience of the crew in the carriage of timber cargoes. Similarly, there is no reference to the hours worked in the previous 24 hours and days in the preceding seven days. Given there is a total crew of 5 including the Master on a two watch system and trading in North European waters, it is difficult to accept there will be an effective SMS in place".

From September to November this year the Paris and Tokyo Memorandums of Understanding on Port State Control will be conducting Concentrated Inspections Campaigns on on crew familiarisation for confined space entry. One suspects that the results will confirm what is already known: Too little is being done to reduce these unacceptable and unnecessary fatalities.